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  • Bodyscapes Patient Form

    Please complete all twelve sections of this form (20 minutes) and click "Submit". If you wish to save and continue the form later, click "Save" (located at each page break). A pop up box from Jotform will appear. Input your email and you will receive an email with your form to complete at your convenience.
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  • 1. General Information

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  • 2. Primary Health Concerns

  • 3. Medical History

  • 4. Chinese Diagnosis

    In order to properly diagnose your condition, check ALL symptoms you currently have (even if you don't think it relates to your current health condition). Some symptoms may be listed more than once or seem unrelated to the organ system.
  • 5. Body Temperature

  • 6. Stress Level

  • 7. Sleep

  • 8. Neuromuscular Pain

  • 9. Physical Activity

  • 10. Diet and Nutrition

  • 11. Men's Health

  • 12. Women's Health

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